RENAL%20FAILURE

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RENAL FAILURE

• Melissa Greer, Ylise Dobson,
• Megan Stacey, Melissa Terpstra,
• Emily Peterson

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The Radical Renal Team

• Dr. McCurly

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The Radical Renal Team

• The Nurses
• McTall McShorty

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The Radical Renal Team

• The Nurses
• McSmall McGiant

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Case Study
Tia Smith is a 26 year old female patient who is
10 hours post-partum following an emergency
C-section for twins. She was 33.5 weeks pregnant
and had a difficult pregnancy with PIH (pregnancy
induced hypertension) and frequent urinary tract
infections. On admission Tia was diagnosed with
HELLP syndrome (hemolysis, elevated liver
enzymes, low platelets) which necessitated
immediate delivery of her babies. During the
C-section Tia became hypovolemic resulting from
massive hemorrhaging and required blood products
and fluid replacements. Tia eventually developed
hypovolemic shock and remained unstable for 2
hours. For the past nursing shift Tia has been
hypotensive with blood pressures ranging from
59/47 to 95/52. Tias urinary output has been
2-12cc/hr of brown cloudy foul smelling urine.
During your morning assessment you discover the
following
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Case contd

• VS T 37.4 P 125bpm R 33 BP 96/62
•  Respiratory Chest is clear fine crackles heard
  throughout all lung fields, there is diminished
  A/E at the bottom of the R L lobes
•  CV S1, S2 audible with pericardial friction,
  bounding rapid pulse
•  Mental Status drowsy and with assistance will
  orient slowly to PPT, pt c/o persistent hiccups
•  Neurovascular edema, skin cool pale, bruises
  observed throughout extremities, skin turgor
  poor, bilateral decreased sensation in feet
•  GI pt c/o NV
•  Genitourinary pt has foley catheter draining
  brown cloudy foul smelling urine at 2-12cc/hr
•  Psychosocial pt very emotional and crying at
  times because she cannot be with her newborn
  babies and is unable to breastfeed, she is
  concerned for their health, and does not
  understand how this happened to her

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So What is Tias diagnosis?
Acute Renal Failure
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Anatomy of the Kidney
http//www.venofer.com/VenoferHCP/Venofer_kidneyFu
nction.html
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Nephron
http//www.venofer.com/VenoferHCP/Venofer_kidneyFu
nction.html
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10 Functions of the Kidneys

• Urine Formation Formed in the nephrons through a
  complex three-step process GF, tubular
  reabsorption, and tubular secretion
• Excretion of waste products eliminates the
  bodys metabolic waste products (urea,
  creatinine, phosphates, sulfates)
• Regulation of electrolytes volume of
  electrolytes excreted per day is exactly equal to
  the volume ingested
• Na allows the kidney to regulate the volume of
  body fluids, dependent on aldosterone (fosters
  renal reabsorption of Na)
• K kidneys are responsible for excreting more
  than 90 of total daily intake
• RETENTION OF K IS THE MOST LIFE-THREATENING
  EFFECT OF RENAL FAILURE

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Renin-Angiotensin System
http//en.wikipedia.org/wiki/ImageRenin-angiotens
in-aldosterone_system.png
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Kidney Function contd

• Regulation of acid-base balance elimination of
  sulphuric and phosphoric acid

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Kidney function contd

• Control of water balance Normal ingestion of
  water daily is 1-2L and normally all but
  400-500mL is excreted in the urine
• Osmolality degree of dilution or concentration
  of urine (particles dissolved/kg urine (glucose
  proteins are osmotically active agents)
• Specific Gravity measurement of the kidneys
  ability to concentrate urine (weight of particles
  to the weight of distilled water)
• ADH vasopressin regulates water excretion and
  urine concentration in the tubule by varying the
  amount of water reabsorbed.

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Still talking about kidney function

• Control of blood pressure BP monitored by the
  vasa recta.
• Juxtaglomerular cells, afferent arteriole, distal
  tubule, efferent arteriole http//www.wisc-online
  .com/objects/AP2204/AP2204.swf
• Renal clearance ability to clear solutes from
  plasma
• Dependent on rate of filtration across the
  glomerulus, amount reabsorbed in the tubules,
  amount secreted into the tubules
• CREATININE
• Regulation of red blood cell production
  Erythropoeitin is released in response to
  decreased oxygen tension in renal blood flow.
  This stimulates the productions of RBCs
  (increases amount of hemoglobin available to
  carry oxygen)

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Kidney function contd

• Synthesis of vitamin D to active form final
  conversion of vit D into active form to maintain
  Ca balance
• Secretion of prostaglandins important in
  maintaining renal blood flow (PGE PGI). They
  have a vasodilatory effect

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Timeline of Events
EMERGENCY C-SECTION
PIH
HELLP
HEMORRHAGE
HYPOVOLEMIC SHOCK
HYPOVOLEMIA
ACUTE RENAL FAILURE
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HELLP SYNDROME

• A syndrome featuring a combination of "H" for
  hemolysis (breakage of red blood cells), "EL" for
  elevated liver enzymes, and "LP" for low platelet
  count (an essential blood clotting element).
• PREGNANCY COMPLICATION - occurring in 25 of
  pregnancies with toxemia or pre-eclampsia.
• Symptoms include-
• Shortness of breath
• H/A
• Dimmed vision
• Nausea
• Dizziness Fainting
• Edema
• Pain in the upper abdomen

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Effects of HELLP on Mom Baby

• Mothers with HELLP are at increased risk for
• Liver rupture, DIC, abruptio placentae, and acute
  renal failure, stroke, seizure, ARD, pulmonary
  edema
• 1st order of tx is management of blood clotting
  issues
• Women with a hx of HELLP are considered at risk
  for future pregnancies
• After delivery, mothers vitals are CLOSELY
  monitored to observe for complications

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Acute Renal Failure
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Definition

• Acute renal failure (ARF) is an abrupt and sudden
  reduction in renal function resulting in the
  inability to excrete metabolic wastes and
  maintain proper fluid electrolyte balance
• It is usually associated with oliguria (urine
  output lt30cc/hr or lt400cc/day), although urine
  output may be normal or increased
• BUN creatinine values are elevated

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Statistics of ARF

• Frequency condition develops in 5 of
  hospitalized patients and 0.5 patients require
  dialysis
• Elderly are at high risk
• Post-op patients
• Mortality the mortality rate estimates vary from
  25-90
• Race no racial predilection is recognized

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Pathophysiology

• ARF may occur in 3 clinical settings
• As an adaptive response to severe volume
  depletion and hypotension, with structurally and
  functionally intact nephrons (Prerenal)
• In response to cytotoxic or ischemic insults to
  the kidney, with structural and functional damage
  (Intrinsic or Intrarenal)
• Obstruction to the passage of urine (Postrenal)

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Phases of Acute Renal Failure

• Clinical progression of reversible RF occurs in
  four phases
• Initiation phase
• Begins with initial insult and ends when oliguria
  develops
• Oliguric phase
• Accompanied by rise in serum concentrations of
  substances usually excreted by kidneys (urea,
  creatinine, ua, organic acids, intracellular
  cations K Mg)
• urinary output lt400cc/day
• May last 1-3 weeks
• Diuretic phase
• The kidneys begin to recover
• Initially produce hypotonie urine d/t increase in
  GFR
• Recovery phase
• Tubular function restored
• Diuresis subsides and kidney begins to function
  normally again

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Prerenal acute renal failure

• Is the most common cause of ARF occurring in
  60-70 of cases
• It is caused by impaired blood flow as a result
  of intravascular depletion, which leads to
  decreased effective circulating volume to the
  kidneys
• In patients with prerenal ARF, the parenchymal is
  undamaged, and the kidneys respond as if volume
  depletion has occurred.

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Prerenal ARF

• Causes include
• Secondary to renal hypoperfusion which occurs in
  setting of extracellular fluid loss
• Diarrhea
• Vomiting
• Diuretics
• Impaired/inadequate cardiac output
• Drugs
• NSAIDs
• ACE Inhibitors
• Hypovolemia
• Hemorrhage
• Renal vasoconstriction

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Intrinsic acute renal failure

• Is the result of actual parenchymal damage to the
  glomeruli or kidney tubules
• A physiologic hallmark is failure to maximally
  concentrate urine
• Is divided into 4 categories
• Acute tubular disease
• Glomerular disease
• Vascular disease
• Interstitial disease

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Intrinsic ARF

• Acute Tubular Necrosis
• most common type of ARF, a more ischemic insult
  to the kidneys, usually induced by ischemia or
  toxins
• Caused by
• Burns, and crush injuries myoglobin
  hemoglobin are liberated causing renal toxicity
  or ischemia
• Drugs NSAIDs, ACE inhibitors, aminoglycosides
• Infections
• Nephrotoxic agents contrast agent
• Glomerulonephritis
• uncommon cause, most associated with CRF
• Caused by
• Can be a primary disorder or can occur secondary
  to systemic disease
• Systemic lupus erythematosus

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Intrinsic ARF

• Acute Interstitial Nephritis
• Interstitial disturbance that leads to ARF
• Caused by
• Allergic reaction to drugs
• Vascular Disease
• Can occur on microvascular and macrovascular
• Caused by
• Microvascular
• Hemolytic anemia
• ARF secondary to small vessel thrombosis or
  occlusion
• Macrovascular
• Suspected in elderly
• Renal artery stenosis or thrombosis
• Atheroembolism secondary to atrial fibrillation
  and aortic disease

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Postrenal acute renal failure

• Is rare and occurs with urinary tract obstruction
  that affects the kidneys bilaterally
• Pressure rises in the kidney tubules, eventually
  the GFR decreases

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Postrenal ARF

• Causes include
• Bladder tract obstruction
• Prostatic hypertrophy
• Catheters
• Neurogenic bladder
• Postrenal causes are typically reversible

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Assessment

• History
• Observe for disorder that predisposes pt to ARF
• Ask questions about recent illness, infections,
  or injuries
• Medication history
• Urinary patterns
• History of GI problems
• Psychosocial
• Anxious
• Family members

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Clinical Manifestations of ARF

• Cardiovascular
• Arrhythmias
• BP, N, high or low
• Anemia
• P, rapid, bounding, or N
• Pericardial-type chest pain
• Respiratory
• Dyspnea
• Crackles
• Tachypnea
• Kussmauls respirations
• Mental Status
• Lethargy
• Tremors
• Memory loss
• Confusion
• Musculoskeletal
• Muscle spasms
• Weakness

• Genitourinary
• Oliguria
• Anuria
• abN urine colour, clarity, smell
• GI
• Moist tongue increased saliva
• Dry tongue mucous membranes
• NV
• Integumentary
• Moist, warm skin pitting edema
• Decreased skin turgor
• bruises
• Pallor
• Thin, brittle hair nails

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Nursing Care Plan

• Fluid volume deficit related to hemorrhage
  (hypovolemic shock)
• Priority to restore fluid balance and circulation
• The patient will
• show stable vital signs
• have adequate urine output gt30cc/hr
• have strong peripheral pulses indicating tissue
  perfusion
• display LOC normal for patient

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Nursing Care Plan

• Interventions
• Bleeding reduction, fluid resuscitation, blood
  product administration, IV therapy
• Monitor VS q2h
• Monitor weight daily
• Skin tongue turgor
• Monitor and document IO
• Monitor CBC, ABG, urinalysis, ECG

• Rationales
• Early intervention can prevent progression of
  hypovolemia to hypovolemic shock that may result
  in renal damage
• SS correlate with the approximate percentage of
  volume loss
• Medullary vasomotor center stimulation via the
  baroreceptor reflex
• ADH
• Foley catheter facilitates monitoring of urine
  output
• Shock pt hemodynamically unstable with
  compromised compensatory mechanisms, volume admin
  may cause fld overload

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Nursing Care Plan

• Electrolyte imbalance related to decreased
  electrolyte excretion, and metabolic acidosis
• Priority to prevent complications of electrolyte
  imbalance
• Within 24h of admission and then continuously,
  the pt will
• Maintain serum electrolyte levels within
  acceptable limits
• Have normal sinus rhythm

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Nursing Care Plan

• Interventions
• Monitor document electrolyte levels q8-12h,
  especially
• K, P, Ca, Mg
• Monitor ABG
• Monitor ECG especially
• High tented T waves, prolonged PR interval or
  widened QRS complex
• Limit dietary drug intake of potassium

• Rationales
• Kidneys ability to regulate electrolyte
  excretion reabsorption may result in high K
  P, low Ca, high/low Mg levels.
• ARF causes metabolic acidosis which may increase
  the release of K from cells in exchange for H
  ions
• Electrolyte abN can trigger arrhythmias cardiac
  arrest
• When kidneys cannot excrete K, excess intake can
  increase serum K to dangerous levels

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Nursing Care Plan

• Knowledge deficit of acute renal failure related
  to lack of exposure to information on management
  of complex condition
• Priority to provide in depth information on acute
  renal failure
• Upon discharge the patient will
• Be able to identify signs and symptoms to report
  to nurse or physician
• Commitment to comply with treatments, including
  dialysis, dietary modifications, and activity
  restrictions

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Nursing Care Plan

• Interventions
• Provide as appropriate information on the
  severity of ARF dialysis
• Stages of ARF
• Medications including action and adverse effects
• SS
• Procedures such as dialysis including schedule
  and adverse effects
• Dietary modifications including limitations of
  proteins (catabolism), electrolytes and fluids
• Rest and activity restrictions

• Rationales
• The patient and family need assistance,
  explanation, and support during this time.
• Teaching may decrease anxiety and fear, and
  enhance recovery to patient and family members.
• Continued assessment of the patient for
  complications of ARF and of its precipitating
  cause is essential.

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Acute Renal Failure

• LAB VALUES

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Medications for ARF

• Pharmacologic treatment of ARF has been attempted
  on an empirical basis, with varying success
  rates. Several promising experimental therapies
  in animal models are awaiting human trials
• It is critical to adjust (decrease or
  discontinue) medication dosages for patient in
  acute renal failure. Administering the average
  dose to patient in renal failure can kill a
  patient.

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Medications for ARF continued

• Immediate goal is to retain fluid volume deficit
  through use of blood products and crystalloids
• Normal Saline (0.9 Na) only one that is
  compatible with blood transfusions
• Restores fluid loss
• Provides electrolytes resembling those of plasma
• Packed RBC
• To increase blood volume
• To restore blood to kidneys

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Medications for ARF continued

• Diuretics
• Furosemide (Lasix) only given with severe fluid
  overload
• Increases excretion of water by interfering with
  chloride-binding cotransport system, which, in
  turn, inhibits sodium and chloride reabsorption
  in the thick ascending loop of Henle and the
  distal renal tubule
• Adult dose 20-80 mg PO/IV once repeat 6-8h prn
  or dose may be increased by 20-40 mg no sooner
  than 6- 8h after previous dose until desired
  effect
• Nursing Assessments Watch for hypokalemia,
  assess BP before and during therapy can cause
  hypotension

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Medications for ARF continued

• Vasodilators
• Dopamine
• In small doses causes selective dilatation of the
  renal vasculature, enhancing renal perfusion.
• Reduces sodium absorption, thereby decreasing the
  energy requirement of the tubules. This enhances
  urine flow, which, in turn, helps prevent tubular
  cast obstruction.
• Adult dose 2-5 mcg/kg/min
• Nursing Assessments Monitor BP during
  administration, stop infusion if BP drops 30mm
  Hg, Monitor IO

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Medications for ARF continued

• Alkalinizer
• Sodium Bicarbonate
• Increases plasma bicarbonate, which buffers
  Hydrogen ion concentration reverses acidosis
• Adult Dose Initial dose IV bolus 1 mEq/kg, then
  infuse 2-5 mEq/kg over 4-8 hr depending on CO2,
  pH
• Dilute with equal amounts of NS, 2-5 mEq/kg
• Nursing assessments Assess resp. and pulse rate,
  rhythm, depth, lung sounds, monitor IO,
  electrolytes, blood pH, PO2, HCO3, monitor urine
  pH, and UO during beginning of treatment, monitor
  for alkalosis, monitor ABGs and blood studies

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13 have passed and now Tia is diagnosed with

• Chronic Renal Failure
• 13 years have passed ? Tia is now 39 years of age
  and has been experiencing declining renal
  function over the past 13 years. Tia has lost
  15lbs on her already small frame, she feels
  generally ill most of the time with frequent NV,
  she suffers from fatigue, muscle twitching
  cramps decreased sensation in her hands and feet
  and generalized puritus. The Physician has
  diagnosed Tia with ESRD and has determined that
  long term dialysis will be required.

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• Chronic Renal Failure
• ESRF

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Definition

• Also known as End-Stage Renal Failure (ESRF), is
  a progressive deterioration in renal function in
  which the bodys ability to maintain metabolic
  and fluid and electrolyte balance fails,
  resulting in uremia (retention of urea and other
  nitrogenous wastes in the blood).
• decreased kidney glomerular filtration rate (GFR)
  of lt60 mL/min/1.73 m2 for 3 or more months

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Statistics

• In the U.S. The US Renal Data System (USRDS) has
  shown a dramatic increase in patients with CRF
  who require chronic dialysis or transplantation.
  In 1999, there were 340,000 such patients, but,
  by 2010, this number is projected to reach
  651,000.
• Internationally The incidence rates of end-stage
  renal disease (ESRD) have increased steadily
  internationally since 1989. The United States has
  the highest incident rate of ESRD, followed by
  Japan. Japan has the highest prevalence per
  million population, with the United States taking
  second place.

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Statistics Contd

• Mortality /Morbidity CRF is a major cause of
  morbidity and mortality, particularly at the
  later stages. The 5-year survival rate for a
  patient undergoing chronic dialysis is
  approximately 35. This is approximately 25 in
  patients with diabetes. The most common cause of
  death in the dialysis population is
  cardiovascular disease.
• Race Affects all races

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Pathophysiology

• As renal function declines, the end products of
  protein metabolism (which are normally excreted
  in the urine), accumulate in the blood. Uremia
  develops and adversely effects every system in
  the body.
• The greater the buildup of waste products, the
  more severe the symptoms.
• Approximately 1 million nephrons are present in
  each kidney, each contributing to the total GFR.
  Regardless of the etiology of renal injury, with
  progressive destruction of nephrons, the kidney
  has an innate ability to maintain GFR by
  hyperfiltration and compensatory hypertrophy of
  the remaining healthy nephrons.
• This nephron adaptability allows for continued
  normal clearance of plasma solutes such that
  substances such as urea and creatinine start to
  show significant increases in plasma levels only
  after total GFR has decreased to 50, when the
  renal reserve has been exhausted. The plasma
  creatinine value will double with a 50 reduction
  in GFR.

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Stages of Chronic Renal Disease

• 3 stages in nephron function
• Stage 1 Reduced Renal Reserve
• Characterized by a 40-75 loss of nephron
  funtion. The patient is usually asymptomatic
  because the remaining nephrons are able to carry
  out normal function of the kidney

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Stage 2 of Renal Disease

• Stage 2 Renal Insufficiency
• Occurs when 75-90 of nephron function is lost.
  At this point, the serum creatinine and BUN rise,
  the kidney loses its ability to concentrate urine
  and anemia develops. The patient may report
  polyuria and nocturia

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Stage 3 of Renal Disease

• Stage 3 End-Stage Renal Disease
• The final stage, occurs when there is less than
  10 of nephron function remaining. All normal
  regulatory, excretory, and hormonal functions of
  the kidneys are severely impaired. ESRD is
  evidenced by elevated creatinine and BUN levels
  as well as electrolyte imbalances.
• Dialysis is usually indicated at this point.

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Glomular Filtration Rate

• GFR a Kidney function test in which results can
  be determined from amount of ultrafiltrate formed
  by plasma flowing through the glomeruli of the
  kidney.
• As glomular filtration decreases, the serum
  creatinine and BUN levels increase.

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Causes

• Type 1 and type 2 diabetes mellitus cause a
  condition called diabetic nephropathy, which is
  the leading cause of kidney disease in the United
  States.  
• High Blood Pressure (hypertension), if not
  controlled, can damage the kidneys over time.
• Glomerulonephritis is the inflammation and damage
  of the filtration system of the kidney and can
  cause kidney failure. Postinfectious conditions
  and Lupus are among the many causes of
  glomerulonephritis.

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More Causes

• Polycystic Kidney Disease is an example of a
  hereditary cause of chronic kidney disease
  wherein both kidneys have multiple cysts 
• Use of analgesics such as acetaminophen (Tylenol)
  and ibuprophen regularly over long durations of
  time can cause analgesic nephropathy, another
  cause of kidney disease. Certain other
  medications can also damage the kidneys.
• Clogging and hardening of the arteries
  (atherosclerosis) leading to the kidneys causes a
  condition called ischemic nephropathy, which is
  another cause  of progressive kidney damage.
• Obstruction of the flow of urine such as by
  stones, an enlarged prostate, strictures
  (narrowings), or cancers may also cause kidney
  disease

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Clinical Manifestation

• Patients with CRF stage 3 or lower (GFR gt30
  mL/min) generally are asymptomatic and do not
  experience clinically evident disturbances in
  water or electrolyte balance or
  endocrine/metabolic disturbances.
• Generally, these disturbances clinically manifest
  with CRF stages 4 and 5 (GFR lt30 mL/min).

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Clinical Manifestations

• Hyperkalemia usually develops when GFR falls to
  less than 20-25 mL/min because of the decreased
  ability of the kidneys to excrete potassium.
• Metabolic acidosis because the kidney cannot
  excrete increased loads of acid.

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Clinical Manifestations

• Extracellular volume expansion and total-body
  volume overload results from failure of sodium
  and free water excretion.
• Anemia principally develops from decreased renal
  synthesis of erythropoietin, the hormone
  responsible for bone marrow stimulation for red
  blood cell (RBC).
• Calcium and Phosphorus imbalance occurs because
  of a disorder in metabolism. They have a
  reciprocal relationship in the body as one
  rises, the other decreases.

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Signs and Symptoms

• Neurologic
• weakness, fatigue, confusion, disorientation,
  tremors, seizures, restlessness of legs, burning
  of soles of feet, behavioral changes.
• Integumentary
• Gray-bronze skin colour, dry, flaky skin,
  pruritus, ecchymosis, thin brittle nails, coarse,
  thinning hair
• Pulmonary
• Crackles, thick tenacious sputum, depressed cough
  reflex, pleuritic pain, shortness of breath,
  engorged neck veins, tachypnea, uremic
  pneumonitis, uremic lung

• Gastrointestinal
• Ammonia odour to breath, metallic taste, mouth
  ulcerations and bleeding, anorexia, NV, hiccups,
  constipation or diarrhea, bleeding from GI tract.
• Hematologic
• Anemia, thrombocytopenia
• Musculoskeletal
• Muscle cramps, loss of muscle strength, renal
  osteodystrophy, bone pain, bone fractures, foot
  drop

61
Nursing Care Plan

• Rationale
• Assessment provides baseline and ongoing database
  for monitoring changes and evaluating
  interventions
• Fluid restriction will determine on the basis of
  weight, urine output, and response of therapy
• Understanding promotes pt and family cooperation
  with fluid restrictions
• Oral hygiene minimizes dryness of oral mucous
  membranes
• Expected Outcomes
• Demonstrates no rapid weight changes
• Maintains dietary and fluid restrictions
• Exhibits normal skin turgour without edema
• Normal vitals
• Reports no difficulty breathing or shortness of
  breath
• Reports decrease dryness of oral mucous
  membranes.

• Excess fluid volume r/t decreased urine output,
  and retention of sodium and water
• Goal is maintenance of ideal body weight without
  access fluid
• Nursing Interventions
• Assess fluid Status
• Daily weight
• I O
• Skin turgour edema
• Distention of neck veins
• BP, P, R
• Limit fluid intake to prescribed volume
• Explain to pt and family rationale for
  restriction of food
• Provide or encourage frequent oral care

62
Nursing Care Plan

• Hyperkalemia, pericarditis, pericardial effusion
  and temponade, hypertension, anemia, bone disease
• Goal Patient experiences and absence of
  complications
• Nursing Interventions
• Hyperkalemia
• Monitor serum K levels and notify physician if
  greater than 5.5 mEq/L.
• Assess patient for muscle weakness, diarrhea, ECG
  changes( tall tented Twaves, widened QRS).

• Rationale
• Hyperkalemia causes potentially life-threatening
  changes to the body
• Cardiovascular S S are characteristic of
  hyperkalemia
• Expected Outcomes
• Pt has normal K level
• Experiences no muscle weakness or diarrhea,
• Exhibits normal ECG pattern
• Vital signs are within normal limits

63

• Pericarditis, Pericardial effusion, tamponade
• Assess for fever, chills, chest pain and
  pericardial friction rub (signs of pericarditis).
• If pt has pericarditis, ax q 4 hrs
• Extreme hypotension
• Weak of absent peripheral pulses, altered level
  of consciousness, bulging neck veins.

• Rationale
• About 30-50 of CRF pts develop pericarditis due
  to uremia fever ,chest pain, and pericardial
  friction rub are classic signs
• Pericardial effusion is common following
  pericarditis. Signs of effsusion paradoxical
  pulse (gt 10 mm drop in BPduring inspiration) and
  signs of shock d/t compression of the heart by a
  lg effusion.
• Cardiac tamponade exists when the pt is severely
  compromised hemodynamically
• Outcomes
• Has strong and equal peripheral pulse
• Absence of paradoxical pulse
• Absence of pericardial effusion, or tamponade

64

• Hypertension
• Monitor and record blood pressure
• Administer antihypertensives as prescribes
• Encourage compliance with dietary and fluid
  restriction therapy
• Teach pt report signs of fluid overload, vision
  changes, headaches, edema, seizures

• Rationale
• Antihypertensives play a key role in tx of
  hypertension associated with CRF.
• Adherence to diet and fluid restrictions prevents
  excess fluid and sodium accumulation
• These are indications of inadequate control of
  hypertension, and need to alter therapy
• Outcomes
• BP is within normal limits
• No headaches, visual problems or seizures
• No edema
• Demonstrates compliance with dietary and fluid
  restrictions

65

• Anemia
• Monitor RBC count, Hg, and HCT levels
• Administer prescribes meds iron and folic acid
• Avoid drawing unnecessary blood specimens
• Teach pt to prevent bleeding avoid vigorous nose
  blowing
• Administer blood component therapy

• Rationale
• Provides Ax of degree of anemia
• RBCs need iron and folic acid to be produced.
• Anemia is worsened by drawing numerous specimens
• Blood component therapy may be needed if pt has
  symptoms
• Outcomes
• Pt has normal colour without pallor
• Hematology values are within acceptable limits
• Experiences not bleeding form any site.

66

• Bone Disease
• Administer the following meds as prescribed
  phosphate binders, calcium supplements, vit D
  supplements
• Monitor serum lab values ( calcium, phosphorus,
  aluminum)
• Assist pt with exercise program

• Rationale
• CRF causes numerous physiologic changes affecting
  calcium, phosphorus and vit D metabolism.
• Hyperphophatemia, hypocalcemia, and excess
  aluminum accumulation are common
• Bone demineraliztion decreases with immobility.
• Outcomes
• Serum calcium, phosphorus, and aluminum levels
  are within acceptable ranges.
• Has no bone demineralization
• Discuss importance of maintaining activity level
  and exercise program.

67
Diet

• Protein restriction b/c urea, uric acid and
  organic acids- the breakdown product of dietary
  and tissue proteins- accumulate rapidly in the
  blood when there is impaired renal clearance.
• The allowed protein must be of high biologic
  value (diary products, eggs, meats). These
  proteins are those that are complete proteins and
  supply the essential amino acids necessary for
  cell growth and repair also maintenance of fluid
  balance, healing and skin integrity, and
  maintenance of immune function.
• Fluid restrictions fluid allowance is usually
  500-600 ml more than the previous days 24 hr
  output.
• Calories are supplied by carbs and fats to
  prevent wasting and malnutrition
• Vitamin supplementation because a protein
  restricted diet does provide the necessary
  amounts of vitamins and the pt on dialysis may
  lose water soluble vitamins from the blood during
  treatment.

68
Chronic Renal Failure

• LAB VALUES

69
Medications for CRF

• Diuretics
• Furosemide (Lasix) only given with severe fluid
  overload
• Increases excretion of water by interfering with
  chloride-binding cotransport system, which, in
  turn, inhibits sodium and chloride reabsorption
  in the thick ascending loop of Henle and the
  distal renal tubule
• Adult dose 20-80 mg PO/IV once repeat 6-8h prn
  or dose may be increased by 20-40 mg no sooner
  than 6-8h after previous dose until desired
  effect
• Nursing Assessments Watch for hypokalemia,
  assess BP before and during therapy can cause
  hypotension

70
Medications for CRF continued

• Phosphate-lowering agents
• Calcium acetate (Calphron, PhosLo)
• Combines with dietary phosphorus to form
  insoluble calcium phosphate, which is excreted in
  feces.
• Adult dose 1-2 g PO bid-tid with each meal
  increase to bring serum phosphate value to 6
  mg/dL as long as hypercalcemia does not develop
• Calcium carbonate (Caltrate, Apo-Cal, Tums)
• Successfully normalizes phosphate concentrations
• Neutralizes gastric acidity, increase serum Ca
• Adult dose 1-2 g PO divided bid-tid with meals
  as a phosphorous binder between meals as a
  calcium supplement

71
Phosphate-lowering agents

• Calcitriol (Rocaltrol, Calcijex)
• Increases intestinal absorption of calcium for
  treatment of hypocalcemia and increases renal
  tubular resorption of phosphate
• Adult dose for hypocalcemia during chronic
  dialysis
• 0.25 mcg/day or every other day, may require
  0.5-1 mcg/day PO
• Sevelamer (Renagel)
• Indicated for the reduction of serum phosphorous
  in patients with ESRD.
• Adult dose Initial 800-1600 mg PO tid with
  mealsMaintenance Increase or decrease by
  400-800 mg per meal q2wk to maintain serum
  phosphorous at 6 mg/dL or less

72
Phosphate-lowering agents

• Lanthanum carbonate (Fosrenal)
• for reduction of high phosphorus levels in
  patients with ESRD
• Adult dose Initial 250-500 mg PO tid pc
  (chewable tabs) adjust dose q2-3wk to target
  serum phosphorus levelMaintenance 500-1000 mg
  PO tid pc

73
Phosphate-lowering agents

• Doxercalciferol (Hectorol)
• To lower parathyroid hormone levels in patients
  undergoing chronic kidney dialysis. Increases
  serum Ca
• Adult dose 10 mcg PO 3 times/wk at dialysis
  increase dose by 2.5 mcg/8 wk if iPTH is not
  lowered by 50 and fails to reach the target
  range not to exceed 20 mcg/3 times/wkAlternative
  ly, 4 mcg IV 3 times/wk may adjust dose by 1-2
  mcg/8 wk to maintain iPTH levels
• Nursing Assessment for all phosphate lowering
  agents Monitor BUN, creatinine, chloride,
  electrolytes, urine pH, urinary calcium, mg,
  phosphate, urinalysis urinary Ca should be
  9-10mg/dl, assess for hypocalcemia headache,
  N/V, confusion

74
Medications for CRF continued

• Anemia
• Epoetin alfa (Epogen, Procrit)
• Stimulates RBC production
• Adult dose 50 -150 U/kg IV/SC 3 times per week,
  then adjust dose by 25 U/kg/dose to maintain
  appropriate Hct maintenance 12.5-25 U/kg,
  titrate to target Hct,
• Nursing Assessment Monitor renal studies
  urinalysis, protein, blood, BUN, creatinine IO.
  Monitor blood studies, Hgb, Hct, RBC, WBC, INR,
  PTT

75
Medications for CRF continued

• Darbepoetin (Aranesp)
• Stimulates erythropoiesis
• Adult dose 0.45 ug/kg IV/SC as a single
  injection, titrate not to exceed a target Hgb of
  12 g/dl
• Has a longer half-life than epoetin alfa
• Nursing Assessments Assess blood studies, renal
  studies assess BP, check for rising BP as Hct
  rises

76
Medications for CRF continued

• Iron Salts
• To treat anemia
• Ferrous sulfate (Feosol, Feratab, Slow FE)
• Replaces iron stores need for RBC development
• Adult dose 100-200mg tid
• Iron sucrose (Venofer)
• Used to treat iron deficiency dute to chronic
  hemodialysis
• Adult dose IV 5ml (100mg of elemental iron)
  given during dialysis, most will need 1000mg of
  elemental iron over 10 dialysis
• Nursing Assessments Monitor blood studies, Hct,
  Hgb, total Fe, monthly. Assess bowel elimination
  for constipation

77
Dialysis
78
What is Dialysis?

• Dialysis is a type of renal replacement therapy
  which is used to provide artificial replacement
  for lost kidney function due to acute or chronic
  kidney failure
• It is a life support treatment, it does not cure
  acute or chronic renal failure
• May be used for very sick clients who have
  suddenly lost kidney function
• May be used for stable clients who have
  permanently lost kidney function
• Healthy kidneys remove waste products (potassium,
  acid, urea) from the blood and they also remove
  excess fluid in the form of urine
• Dialysis has to duplicate both of these functions
• Dialysis waste removal
• Ultrafiltration fluid removal

79
Principle of Dialysis

• Dialysis works on the principle of diffusion of
  solutes along a concentration gradient across a
  semipermiable membrane
• Blood passes on one side of the semipermeable
  membrane, and a dialysis fluid is passed on the
  other side
• By altering the composition of the dialysis
  fluid, the concentrations of the undesired
  solutes (potassium, urea) in the fluid are low,
  but the desired solutes (sodium) are at their
  natural concentration found in healthy blood

80
Prescription for Dialysis

• A prescription for dialysis is given by a
  physician who specializes in the kidney
  (nephrologist)
• The MD will set various parameters for the
  treatment
• Time and duration of the dialysis sessions
• Size of the dialyzer
• Rate of blood flow

81
2 Main Types of Dialysis

• Hemodialysis
• Peritoneal Dialysis

82
Hemodialysis
Adapted from National Institute of Diabetes and
Digestive and Kidney Diseases. National
Institute of Diabetes and Digestive and Kidney
Diseases. End-stage renal disease choosing a
treatment that's right for you. Available at
http//www.niddk.nih.gov/health/kidney/pubs/esrd/e
srd.htm. Accessed May 10, 2000.
83
What is Hemodialysis (HD)?

• Clients blood is passed through a system of
  tubing (dialysis circuit) via a machine to a
  semipermeable membrane (dialyzer) which has the
  dialysis fluid running on the other side
• The cleansed blood is then returned via the
  circuit back to the body
• The dialysis process is very efficient (much
  higher than in the natural kidneys), which allows
  treatments to take place intermittently (usually
  3 times a week), but fairly large volumes of
  fluid must be removed in a single treatment which
  can be very demanding on a client

84
Side Effects of HD

• The side effects are proportionate to the amount
  of fluid being removed
• Decreased blood pressure
• Fatigue
• Chest pains
• Leg cramps
• Headaches
• Electrolyte imbalance
• NV
• Reaction to the dialyzer
• Air embolism

85
Complications of HD

• Because HD requires access to the circulatory
  system, clients have a portal of entry for
  microbes, which could lead to infection
• The risk of infection depends on the type of
  access used
• Bleeding may also occur at the access site
• Blood clotting was a serious problem in the past,
  but the incidence of this has decreased with the
  routine use of anticoagulants (Heparin is the
  most common)
• Anticoagulants also come with their own risk of
  side effects and complications

86
Rare Complication of HD

• On the rare occasion, a client may have a severe
  anaphylactic reaction
• Sneezing
• Wheezing
• SOB
• Back pain
• Chest pain
• Sudden death
• This can be caused by the sterilant in the
  dialyzer or the material in the membrane itself

87
Three Types of Access for HD

• IV catheter
• Arteriovenous (AV) fistula
• Synthetic graft
• The type of access is influenced by factors such
  as expected time course of the clients renal
  failure and the condition of the clients
  vasculature
• Some clients may have multiple accesses, usually
  because an AV fistula or a graft is maturing and
  an IV catheter is still being used

88
IV Catheter (Central Venous Catheter)

• Consists of a plastic catheter with two lumens
  which is inserted into a large vein (vena cava
  via the internal jugular vein) to allow large
  flows of blood to be withdrawn from the first
  lumen
• The blood goes into the dialysis circuit, and is
  returned to the body via the second lumen
• Non-tunneled
• Tunneled
• This type of access is used for clients who need
  rapid access for immediate dialysis
• Clients who are likely to recover from ARF
• Client with end-stage renal failure
• Clients waiting for other sites to mature
• This type of access is very popular for clients
  because it doesnt involve needles for each
  treatment

89
Complications of an IV Catheter

• Venous Stenosis
• This is the abnormal narrowing of the blood
  vessel
• Because the catheter is a foreign body in the
  vessel, it often provokes an inflammatory
  reaction in the vein wall
• This results in scarring and narrowing of the
  vein, often to the point where the vein occludes

90
AV Fistula

• This access is recognized as the preferred access
  method
• To create a fistula a vascular surgeon joins an
  artery and a vein together
• Since this bypasses the capillaries, blood flows
  at a very high rate through the fistula
• This can be felt by placing a finger over a
  mature fistula (thrill)
• Usually created in the non-dominant hand
• It can be situated on the hand, forearm or the
  elbow
• It will take approximately 4-6 weeks to mature
• During treatment, 2 needles are inserted, one to
  draw blood out of the body and the other to
  return blood to the body

91
Advantages of an AV Fistula

• Decreased infection rate
• Increased blood flow rates, therefore a more
  effective dialysis treatment
• Decreased incidence of thrombosis

92
Complications of an AV Fistula

• If an AV fistula has a very high flow rate and
  the vasculature that supplies the rest of the
  limb is poor, than a steal syndrome can occur
• Blood that enters the limb is drawn into the
  fistula and returned to the general circulation
  without entering the capillaries of the limb
• This results in cool extremities of the limb,
  cramping pains and possible tissue damage
• Long term complications can be the development of
  a bulging in the wall of the vein (aneurysm)
• The vessel wall is weakened by the repeated
  insertion of needles over time
• Can be reduced by careful needling technique

93
AV Graft

• This is much like a fistula, except an artificial
  vessel is used to join the artery and the vein
• Grafts are used when clients own vasculature
  does not permit a fistula
• An AV graft will mature much faster than an AV
  fistula, and it could be ready to use within days
  after formation

94
Complications of an AV Graft

• AV grafts are at high risk for narrowing where
  the graft is sewn to the vein
• As a result clotting or thrombosis may occur
• As a foreign material is being placed in the
  body, there is a greater risk of infection

95
Equipment Needed for HD

• The HD machine performs the function of pumping
  the patient's blood and the dialysate through the
  dialyzer.
• The newest dialysis machines on the market are
  highly computerized and continuously monitor an
  array of safety-critical parameters, including
  blood and dialysate flow rates, blood pressure,
  heart rate, conductivity, pH, etc.
• If any reading is out of normal range, an audible
  alarm will sound to alert the patient-care
  technician who is monitoring the patient.

96
Equipment Water System

• An extensive water purification system is
  absolutely critical for HD
• Since dialysis patients are exposed to vast
  quantities of water, which is mixed with the acid
  bath to form the dialysate, even trace mineral
  contaminants or bacterial endotoxins can filter
  into the patient's blood.
• Because the damaged kidneys are not able to
  perform their intended function of removing
  impurities, ions that are introduced into the
  blood stream via water can build up to hazardous
  levels, causing numerous symptoms including death
  
• For this reason, water used in HD is purified

97
Equipment The Dialyzer

• The dialyzer, or artificial kidney, is the piece
  of equipment that actually filters the blood
• The blood is run through a bundle of very thin
  capillary-like tubes, and the dialysate is pumped
  in a chamber bathing the fibers
• The process mimics the physiology of the
  glomerulus and the rest of the nephron
• Dialyzers come in many different sizes. A larger
  dialyzer will usually translate to an increased
  membrane area, and an increase in the amount of
  undesired solutes removed from the patient's
  blood.
• The nephrologist will prescribe the dialyzer to
  be used depending on the patient
• Dialyzers are not shared between patients in the
  practice of reuse.

98
Peritoneal Dialysis
99
What is Peritoneal Dialysis (PD)?

• Peritoneal dialysis works by using the body's
  peritoneal membrane, which is inside the abdomen,
  as a semi-permeable membrane.
• A specially formulated dialysis fluid is
  instilled around the membrane, using an
  indwelling catheter, then dialysis can occur, by
  diffusion
• Excess fluid can also be removed by osmosis, by
  altering the concentration of glucose in the
  fluid.
• Dialysis fluid is instilled via a peritoneal
  dialysis catheter, which is placed in the
  patient's abdomen, running from the peritoneum
  out to the surface, near the navel
• Peritoneal dialysis is typically done in the
  patient's home and workplace, but can be done
  almost anywhere

100
Advantages of PD

• Can be done at home
• Relatively easy for the client to learn
• Easy to travel with, bags of solution are easy to
  take on holiday
• Fluid balance is usually easier when the client
  is on PD than if the client is on HD

101
Disadvantage of PD

• Requires a degree of motivation and attention to
  cleanliness while performing PD
• There are a number of complications

102
Complications of PD

• Peritoneal dialysis requires access to the
  peritoneum. As this access breaks normal skin
  barriers, and as people with renal failure
  generally have a slightly suppressed immune
  system, infection is a relatively common problem
• Long term peritoneal dialysis can cause changes
  in the peritoneal membrane, causing it to no
  longer act as a dialysis membrane as well as it
  used to.
• This loss of function can manifest as a loss of
  dialysis adequacy, or poorer fluid exchange (also
  known as ultrafiltration failure)
• Fluid may leak into surrounding soft tissue,
  often the scrotum in males
• Hernias are another problem that can occur due to
  the abdominal fluid load

103
Nursing Assessments

• Before client is in the unit, look at the nurses
  notes from the treatment before
• Any problems, will help nurse plan for the
  upcoming treatment
• Look at the client
• Strength
• Gait
• Whether client needs assistance
• Color
• Puffiness
• Could be caused by excess fluid, too much to
  drink, more fluid should be taken off with each
  treatment, changes in voiding pattern (are they
  voiding less than they did last month)

104
Assessments Cont

• Shortness of breath
• Could indicate fluid around the lungs
• Ask about SOB at night (does client have to sleep
  in a sitting position?)
• Ask the client how they are feeling
• The client is usually the best source of
  information
• Clients are in 3 times a week, dialysis nurses
  really get to know their clients
• Evaluate access
• Bruising, swollen, tender
• Bruit listen with the stethoscope for a
  swishing sound of the blood, listen all the way
  up the arm
• Thrill felt with the fingers, tells the nurse
  if the blood is flowing in the fistula (clients
  are told to feel for this at home when a fistula
  is first initiated)

105
Assessments During Treatment

• Ask client how he/she feels
• Dizziness, diaphoretic,
• The machines automatically take BP and HR every
  30 minutes
• Can program the machines to take it at whatever
  interval is necessary (every min, 10 min, 15 min)
• Try to recognize a problem before it starts (ex.
  Hypovolemic shock)
• Assess access site
• Watch trend of BP
• It usually gradually decreases throughout the
  course of the treatment, but look for sudden or
  drastic drops
• Assess access site
• Bleeding, swelling, tenderness

106
Nursing Interventions

• If client comes in with shortness of breath,
  offer O2 which can be kept on for the full
  treatment if necessary
• Comfort
• Clients are sitting in the same chair for up to
  four hours
• Offer extra pillows, some clients have special
  back pillow they leave in the unit
• Ensure TV and audio is working properly

107
Nursing Interventions Cont

• If the blood pressure is dropping too quickly
• Slow or stop fluid removal for a time period
• The machines are constantly being adjusted
  throughout the course of the treatment depending
  on the BP
• If the BP drops suddenly 200-300cc of normal
  saline can be given to balance fluid levels
• Usually, more fluid will be taken off at the
  beginning of the treatment, this will allow the
  client to feel better at the end
• If the client is elderly, fluid removal starts
  slowly to ease them into the treatment

108
Responsibilities of Nursing StaffPrior to
Dialysis

• Ensure client is ready to sit for up to four
  hours
• Encourage client to use washroom before arriving
  to the unit
• Try to avoid laxatives if possible before
  treatment
• Ensure client has eaten meal prior to treatment

109
Responsibilities of Nursing StaffAfter Dialysis

• A dialysis nurse will give unit leader or primary
  nurse a verbal report of treatment
• Any complications during treatment
• Check BP standing and sitting
• Assess access site
• Encourage client to rest
• Avoid treatments or physio for a couple of hours
  if possible
• Watch fluid intake
• Be aware if client is on fluid restriction
• Check thrill and bruit
• Do not take a BP on access arm
• Do not take blood from access arm

110
Questions? Thank you for listening.